Critical Illness Cover

An insurer must not turn down claims unreasonably, and must fairly assess whether a policyholder has met the policy definition of total permanent disability based on their ability to perform the material and substantial duties of their own

An insurer must not unreasonably decline a critical illness claim, and cannot rely on a pre-existing risk exclusion unless it is fairly established that the policyholder was aware of an increased risk before cover commenced.

An insurer must administer policies with reasonable care and where errors cause repeated distress and inconvenience, fair compensation should reflect the cumulative impact on the consumer.

A financial services provider is responsible for ensuring proper administration of policies, including maintaining correct customer contact details and promptly implementing requested updates to customer information.

Insurers must handle claims promptly and fairly, and must communicate clearly with claimants about timescales and processes involved.

An insurer must deal with a claim promptly and fairly and not unreasonably decline it, applying policy definitions that are clear and correctly communicated to the consumer.

An insurer must deal with claims promptly and fairly, and not unreasonably decline them; the policy requires clear medical prognosis that disability will last throughout life with no prospect of improvement.

An insurer must handle claims promptly and fairly, and should assess PTD claims based on the policyholder's ability to carry out their normal occupation as defined in the policy terms.

An insurer is entitled to reasonably request additional information from third parties to validate a claim before determining liability, provided the policyholder has given appropriate authorization.

A claim for total permanent disability under a critical illness policy requires evidence that symptoms are both permanent and irreversible, not merely that the underlying condition is incurable.

Critical illness policy claims must meet the specific contractual definitions set out in the policy terms, and insurers may reasonably decline claims where the insured's condition does not satisfy all required criteria.

A bank is only required to reimburse a customer under the CRM Code where the customer was the victim of a scam, defined as transferring funds for what they believed were legitimate purposes but which were in fact fraudulent.

An insurer is entitled to investigate potential non-disclosure when new information comes to light that conflicts with answers given in the original application.

A policyholder must be unable to perform at least two of the defined Functional Ability Tests to meet the policy's Total Permanent Disability criteria, not merely find them difficult or require pacing.

A consumer is not entitled to claim a higher benefit amount based on incorrect verbal information when the policy terms specify a lower amount, though compensation may be due for distress caused by the error.

A non-advised information provider does not treat a customer unfairly by providing factual policy information without recommending a particular course of action, provided the customer is made aware of their options including cancellation.

Under CIDRA, a consumer must take reasonable care not to misrepresent health information when applying for insurance; if a qualifying misrepresentation occurs, the insurer may decline claims and cancel the policy.

Under CIDRA 2012, an insurer may decline a claim and unwind a policy for careless misrepresentation where the consumer failed to disclose material medical information in response to clear application questions.

Insurers may fairly exclude claims under group critical illness policies where the insured person had an associated condition prior to the cover commencement date, as clearly set out in the contract terms.

A critical illness policy definition of 'irreversible' hearing loss requires that the condition cannot be reasonably improved by medical treatment or surgical procedures available on the NHS, not that it must be completely reversed.

An insurer can decline a TPD claim where the claimant fails to provide specialist confirmation that their disability will last throughout life with no prospect of improvement whilst still covered under the policy.

Pre-existing condition exclusions in group critical illness policies apply fairly when a condition existed (was diagnosed, treated, or known) prior to the date of policy inclusion, regardless of whether the claimant was aware of the full di

A critical illness policy can only pay out when the policyholder meets one of the specified covered conditions listed in the policy terms.

An insurer must not make material errors about policy terms and must provide fair compensation for service failures even where the underlying claim decision was correct.

A financial adviser must provide advice that balances suitable cover with the client's stated affordability constraints, and the suitability of that advice is assessed based on circumstances at the time of the sale, not with hindsight.

An insurer must assess claims fairly and promptly by reviewing medical evidence before determining liability, though it should aim to be clear about policy requirements from the outset.

Under CIDRA 2012, an insurer can apply proportionate remedies for careless misrepresentation if they would have offered the policy at different terms had the consumer disclosed all material facts.

Under CIDRA 2012, a consumer must take reasonable care not to make a misrepresentation when taking out insurance, and an insurer can refuse a claim if the misrepresentation is qualifying and the consumer failed to meet the reasonable care s

Under CIDRA 2012, an insurer may unwind a policy from inception if the consumer failed to take reasonable care when answering health questions, resulting in a qualifying misrepresentation.

A critical illness policy only pays out when the policyholder is diagnosed with a condition that meets the policy's definition; a misdiagnosis that is later corrected does not trigger a valid claim if the final confirmed diagnosis is not co

An insurer may cancel a policy following a discussion about overinsurance if the policyholder is given clear information about which policy is being cancelled and the option to seek independent advice.

An insurer must assess claims according to the definition of total and permanent disability specified in the policy schedule, which cannot be changed or substituted after policy inception.